Formularies in the United States are normally published by health insurers on an annual basis, with minor updates during the year. It is critical that health insurers update their published Formularies following these minor updates.
Insurers regularly administer multiple health insurance and drug coverage plans and each of those plans may have its own formulary.
Each formulary contains a list of drugs. Drugs are placed into tiers that largely determine the cost to the consumer/patient. The number and purpose of drug tiers varies across payers. Each tier has an associated cost-sharing model that includes deductibles and/or coinsurance components for drugs in the tier when purchased through various pharmacy types.
In addition to the drug tier, drugs may also list requirements on the patient (e.g., age or gender) or limitations on prescription (e.g., prior authorization).
Implementation templates included
See the RAML asset for the API specification.
|CoveragePlan||The CoveragePlan profile of the FHIR R4 List resource provides links to information about the plan and formulary, contact information, a description of the drugTiers and associated cost sharing models of the plan, and a list of FormularyDrugs.|
|FormularyDrug||The FormularyDrug profile of the FHIR R4 MedicationKnowledge resource provides plan-specific information about a prescribable drug identified by an RxNORM identifier|